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Oral Radiology

To Implant or Not To Implant: What Role Does Imaging Play?

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This case is presented by the University of Toronto, Department of Oral Radiology Residents: Edwin Chang, Sherif El Saraj, Catherine Nolet-Levesque, Daniel Turgeon,  Niloufar Amintavakoli, and Trish Lukat.  Pre-operative images provided courtesy of Dr. Milan Madhavji of Canaray | Specialists in Oral Radiology.

Check the case follow-up: Click Here

A 72-year old female patient of African-American descent presented to an Oral and Maxillofacial Radiology clinic for pre-operative dental implant imaging.  Cone beam CT examination yielded the following images:

Axial cone beam CT cross-sectional image at the level of the mandibular alveolar process

fig1 axial

Rendered panoramic reconstruction from cone beam CT data set

fig2 rendered_pan

Bucco-lingual cone beam CT cross-sectional images through the anterior mandible

fig3 bucco-lingual

What is your interpretation of the radiographic abnormality observed in these images? Does this finding pose any potential problems with regional implant placement?

21 Comments

  1. Mark Venditti February 7, 2013

    My interpretation of the abnormality is … what the heck is that? My thought would be to figure out what that is before considering placing implants. Assuming the abnormality is not a problem, 2 implants with locators to support a complete denture would be a reasonable treatment plan I believe.

    Reply
    1. Everett Wu February 12, 2013

      I am having trouble enlarging this picture. My first question would be to get a radiograph with her teeth still present if available and assess a timeframe of the radiopacity. I would attempt to rule out Periapical cementosseous dysplasia as she is an african american female.

      I would also check to see if this is an anterior loop from the mental nerve or an incisive canal. This can be confirmed through connecting it through other slices. If it is a connection it would post significant complications.

      I would not assume at this point for this to be malignant as it is generally not in the proper area. If all things came back negative above I would either biopsy it depending on how it presented clinically or place the implants informing the patient of the abnormality and possible increased risk of complication.

      During surgery assessment of the bone would dictate a lot.

    2. RadiologyUofT February 13, 2013

      When evaluating any cone beam CT volume, the starting point is to have a firm sense of “what does normal look like?” Without this knowledge, it is very difficult to appreciate abnormalities! The bucco-lingual cross-sectional images in Figure 3 demonstrate a normal appearance of the cortical and cancellous bone inferiorly. However, as we look more superiorly (toward the alveolar crest), the normal pattern of trabeculation and intervening bone marrow spaces expected within the cancellous bone is not evident. What types of conditions within the jaws can alter the normal bone pattern?

  2. J February 8, 2013

    DD: PCD, osteoma or md tori??

    Reply
  3. Anil Shetty February 8, 2013

    Periapical cemental dysplasia is the first thing that comes to mind . The lesion would need to be surgically removed if you are planning to place implants in the area.
    The other treatment option would be to leave the lesion as it is a benign asymptomatic lesion and place the implants in the premolars – molar area and locators with complete dentures makes sense. A yearly follow up of the lesion would be ideal if left untreated.

    Reply
  4. BRobinson February 12, 2013

    Peri apical cemental dysplasia – highly cortical and type 1++++ bone. So, vascularity very poor .. Make pt aware that high failure percentage – not aware of studies with this type of bone. Expect to tap under copious saline and to repeat allowing insertion torque resistance to be 30 or less …. Use a two stage approach. B.

    Reply
  5. Joy Maru February 12, 2013

    No problem placing implants at all. FO dysplasia, CT was unnecessary. Have placed implants in 4-5 similar cases over a decade ago with no failures so far.

    Reply
  6. Alvin Choi February 12, 2013

    From the history looks and sounds like some kind of benign fibrous osseous lesion. May want to confirm with a radiologist. But agree with Mark’s plan otherwise.

    Reply
  7. Nat Podilsky February 12, 2013

    The cross sectional images are small but it looks like an odontoma. It would be extremely difficult to place implants here due to the calcifications. Recomended treatment is surgical removal of teh odontoma before implant placement.

    Reply
  8. Bob Clinton February 12, 2013

    Possible residual periapical cemental dysplasia. Most common in females of african – american descent.

    Reply
  9. Tom Pater February 12, 2013

    Looks like cemental dyplasia or an ossifying fibroma. Benign origin. If 2 implants desired place in premolar area and do not worry about it. If 4 desired place mini implants; less probability of burning bone but warn the patient of the situation in writing. If 5-6 desired place 6 small diameter (3.0) and warn the patient; longer implants to engage superior and inferior healthy bone. Do not remove, she is too old and surgery will not accomplish much. If patient desires removal then remove, full macro and microbiological studies and do PhD doctoral dissertation defence.

    Reply
  10. Josh Resnick February 12, 2013

    Links to close up of the pictures are broken. PCD would be my guess given the sex, location and ethnic heritage. Florrid-osseous dysplasia perhaps might present issues i.e. osteomyelitis. Any other medical issues – i.e. Pagets or other bone pathology. Older rads before loss of the teeth would be beneficial.

    If no other pathologies present, perhaps place the implants and take a sample of bone to r/o pathology.

    Given the age of the patient and her obvious history with a removable prosthesis, I’d go with a implant retained removable denture with a 2 stage protocol. Although not ideal it might be possible to use other areas to provide support for the prosthesis.

    Reply
    1. RadiologyUofT February 13, 2013

      We are working with the site administrators to provide larger images… thank you for your input!

  11. Waji Khan February 13, 2013

    Why a CBCT at this point? PCD would be on the top of my list but I would first get a more detailed history prior to ordering any further imaging.

    Reply
    1. RadiologyUofT February 13, 2013

      To clarify, the cone beam CT was not performed to “diagnose” the abnormality in the anterior mandible, but rather for pre-operative implant site assessment. The finding under discussion was essentially an incidental finding.

  12. Terry Lim-Prosthodontist February 14, 2013

    I wonder if it is florid osseous dysplasia with patient being african american female. If it is, then a Radiology consult would be recommended due to risk of osteomyelitis if the lesion is exposed as it would be in an implant surgery. What does the U of T radiologists think?

    4 implants and a fixed hybrid would be ideal due to number of natural teeth in the maxilla. There might be issues with asymmetric loading and increased force on the lower denture if it is retained with just two implants.

    Reply
  13. Mark Nicolucci February 14, 2013

    That is an odd appearance for a dense bone island / idiopathic osteosclerosis. Fibro-osseous dysplasia would be high on my Ddx but since the lesion is relatively coronal and because the ridge requires alveoplasty, surgical exploration at the time of implant placement would be easily accomplished. After accessing the lesion, a better decision can be made whether it needs to be removed or not, dependant on whether a soft tissue component exists.

    Reply
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